HA prelims Flashcards
According to ANA, 2010, a nurse’s scope of practice puts emphasis on diagnosis and treatment of human response based on what?
Accurate Client Assessments
What is the standard 1 of Accurate client assessment?
Collects comprehensive data pertinent to the patient’s health or situation
How should you collect data?
In a systemic and ongoing process
True or False:
You should not involve the patient, family and other health care providers and environment in holistic data collection
False
You should involve the patient, family and other health care providers and environment in holistic data collection
How should you prioritize data collection activities?
Based on immediate condition, or anticipated needs
Standard 1 in accurate client assessment uses what assessment techniques and instruments?
Appropriate evidence-based and analytical models and problem-solving tools
Standard 1 synthesizes available data, information and knowledge relevant to the situation to do what?
Identify patterns
How do you document relevant data?
In a retrievable format
What is the standard 2 of Accurate client assessment?
Analyzes the assessment data to determine diagnoses or issues
What is the 3 steps in standard 2 of Accurate client assessment
- Derives the diagnosis based on assessment data
- Validates the diagnoses or issues with the client, family or health care providers
- Document diagnoses or issues to facilitate determination of outcomes and plans
The most marketable nurses will continue to be those with _____ and _____ as well as those who are ______
Strong assessment, client teaching abilities, and technologically savvy
Keep in mind the 5 trends
- Increased focus on primary care
- Increasing complexity of acute care
- Growing aging population
- Intensifying mental health issues
- Expanding service networks
The purpose of nursing assessment is to collect _______ to determine ______ in order to make a ______
Holistic subjective and objective data, overall level of functioning, professional clinical judgment
The nurse collects what 5 types of data about the client
Physiologic, psychological, sociocultural, developmental, and spiritual
Is used to organize information and promote the collection of holistic data
Framework
Generic/ basic sections of framework includes 5 what?
- History of present health concern
- Personal Health History
- Family History
- Lifestyle and Health Practices
- Physical Assessment
Types of Health Assessment
- Initial Comprehensive Assessment
- Ongoing/partial Assessment
- Focused/Problem-oriented Assessment
- Emergency Assessment
Identify the type of assessment:
1. Subjective data about the client’s perception of health
2. Past health history
3. Family history, lifestyle and health practices
4. Objective data gathered from physical examination
Depends on age, risk factors, health status, health promotion and lifestyle
Initial Comprehensive Assessment
Is needed when the client first enters a health care system and periodically thereafter
A total health assessment
Identify the type of assessment:
1. Consists of data collection that occurs after the comprehensive database established
2. Mini-overview of the client’s body systems and holistic patterns as a follow-up on health status
3. Reassessment of health problems detected to determine changes and detect any new problems
4. Performed whenever the nurse encounters a client
5. Determined by acuity of the client
Ongoing/ partial assessment
Identify the type of assessment:
1. Performed when a comprehensive database exists for a client who comes to a healthcare facility with a specific health concern
2. Consists of through assessment of a particular client problem and does not address areas not related to the problem
Focused/ Problem-oriented assessment
Identify the type of assessment:
1. Very rapid assessment performed in life-threatening situations to provide prompt treatment
2. Used to determine the status of the client’s life-sustaining physical functions
Emergency Assessment
What assessment should be done at this time:
Patient was admitted to the medical surgical ward for the first time in preparation for an abdominal surgery
What assessment should be done at this time:
Patient was admitted due to gunshot wound and bleeding profusely
What assessment should be done at this time:
Patient was admitted 3 days ago for evaluation of anti-cancer medication side effects
What assessment should be done at this time:
Patient was admitted to the medical surgical ward for monitoring of respiratory status
Is the first and most critical phase of the nursing process
Nursing Assessment
What are the steps of health assessment?
- Collection of subjective Data
- Collection of objective Data
- Validation of Data
- Documentation of Data
True or False:
If data collection is inadequate or inaccurate, incorrect nursing judgements may be that adversely affect the remaining phases of the process: diagnosing, planning, implementation, and evaluation
True
Information collection/ gathering data
Assessment
Information interpretation, stating problems and strengths
Diagnosis
Setting nursing goals desired outcomes and planning interventions
Outcome/ Planning
Performing nursing interventions
Implementation
Patient’s status and effectiveness of nursing interventions
Evaluation
Based on the nursing scope of practice, the nurse “collects comprehensive data pertinent to the patient’s health or situation which include:
Collects data in
a systematic and ongoing process
Helps organize information and promotes collection of holistic data
A nursing framework
What is the first step of Health assessment?
Collection of subjective data
Before meeting the client, what should you do?
Review client’s medical record, if available
Sensations/ symptoms, perceptions, desires, preferences, beliefs, ideas, values and personal information that can be elicited and verified only by the client
Subjective data
Provides a focus for the physical exam and identify potential nursing diagnoses. It should begin with an explanation to the client of why the information is being requested
Health history
What does health history include?
- Biographic data
- Reasons for seeking health care
- History of present health concern
- Family health history
- Review of body systems
- Lifestyle and health practices profile
- Developmental Level
When students are collecting information and sharing in a form of academic discussion, what must be done?
Identifiable information must be deleted, and initials are used to protect the client’s privacy
The client is considered a _____ of biographic data and all others are _____
primary sources, secondary sources
To check for the reliability of the client as a source of information, what can you do?
Ask immediate family members or caregiver to give detailed data regarding the patient
The most significant health concern of a patient
Chief complaint
COLDSPA
Character
Onset
Location
Duration
Severity
Pattern
Associated factors/How it Affects the client
COLDSPA Symptom analysis:
- Describe the sign or symptom
- “What does the pain feel like?”
Character
COLDSPA Symptom analysis:
- when did it begin
- “when did this pain start?”
Onset
COLDSPA Symptom analysis:
- Where is it? Does it radiate? Does it occur anywhere else?
- “where does it hurt the most? Does it radiate or go to any other part of your body?”
Location
COLDSPA Symptom analysis:
- how long does it last? does it recur?
- “How does the pain last? Does it come and go or is it constant?”
Duration
COLDSPA Symptom analysis:
- How bad is it? How much does it bother you?
- “How intense is the pain? rate it on a scale of 1 to 10”
Severity
COLDSPA Symptom analysis:
- What makes it better or worse?
- “what makes your back pain worse or better? are there any treatments you’ve tried that relieve the pain”
Pattern
COLDSPA Symptom analysis:
- what other symptoms occur with it? how does it affect you?
- “what do you think caused it to start? do you have any other problems that seem related to you back pain? how does this pain affect your life and daily activities?”
Associated factors/ How it affects the client
PQRST
Provoking/Relieving, Quality, Region and radiation, Severity, Time
Personal Health History compromises of 4 what?
- Childhood illnesses and immunizations
- Adult co-morbidities
- Past surgeries/accidents
- Prolonged episodes of pain, allergies and prescription medications
Includes many genetic relatives as the client can recall. Includes maternal and paternal grandparents, aunts and uncles, parents, siblings ang children
Family history
What do you use in organizing family history of patient?
Genogram
In a genogram females are indicated by a _____ while males are a _____
circle, square
In a genogram if relatives has no problems, write_____, if deceased, they are noted by an _____
A/W (alive and well), X
True or false:
In review of systems, care must be taken to include only the client’s subjective information and not the nurse’s observations
True
Deals with human responses, which includes nutritional habits, activity and exercise patterns, sleep and rest patterns, self-concept and self- care activities, social and community activities, relationships, values and
beliefs system, education and work, stress level and coping style and environment
Lifestyle and health practices profile
11 Life style and health practices profile
- Description of typical day
- Nutrition and weight management
- Activity Level and Exercise
- Sleep and Rest
- Self-concept and self-care responsibilities
- Social Activities
- Relationship
- Values and Belief System
- Education and Work
- Stress Levels and Coping Styles
- Environment
Overview of the client’s usual daily activity
Description of typical day
Recalls 24-our intake with emphasis of what foods are eaten and in what amounts. This also considers how much fluid intake is consumed
Nutrition and Weight Management
Assess how active the client is during an average week
Activity Level and Exercise
What is the recommended exercise regimen of aerobic exercise?
20-30 mins
Whether the client is getting enough quality sleep and rest
Sleep and Rest
Sleep and Rest Screening tools:
Ten true/false questions
The sleep disorders screening survey (Division of sleep medicine, Harvard Medical School, 2007)
Sleep and Rest Screening tools:
(Getbettersleep.com, 2009). A several-page list
of symptoms partitioned to address the following sleep disorders: insomnia;
exces- sive daytime sleepiness; depression; hypothyroidism; obstructive sleep
apnea; heartburn or reflux disease (GERD); nocturnal myoclonus (limb and leg
symptoms); nasal or sinus issues, allergies, asthma, or lung disease; circadian
rhythm disorder; hypersomnia; narcolepsy; and parasomnias
Sleep Disorder Screening Tests
Sleep and Rest Screening tools:
A 17-item Likert-like scale with interpretation of results
The Insomnia Screening Questionnaire
Assessment of how the client view herself including sexual responsibility, basic hygiene practices, regularity of health care checkups, breast/testicular self-exam, and accident and hazard protection
Self-Concept and Self-Care Responsibilities
Helps the nurse discover outlets the client has for support and relaxation and if the client in involved in the community beyond the family and work
Social Activities
Client describes the composition of the family into which they were born and about past and current relationships with these family members
Relationships
Assesses the client’s values, philosophical, religious and spiritual beliefs. Note that not all clients are comfortable discussing their feelings and should be respected
Values and Belief System
Identify areas of stress and satisfaction in the client’s life, should bring about kind and amount of education the client has, did the client enjoy school or what he/she perceives his/her education
Education and Work
Investigate amount of stress the clients perceive they are under and how they cope, how they address events and how they usually respond
Stress Levels ang Coping Styles
Asses health hazards unique to the client’s living situation and lifestyle
(Possible questions may include:
What risks are you aware of in your environment?
* What type of precautions do you take, if any, when playing
contact sports, using chemicals or operating machinery?
* Do you believe you are ever in danger of becoming a victim of
violence?)
Environment
What is the second step of Nursing Assessment?
Collection of Objective Data
Also known as the Physical Examination and the information about the client that the nurse directly observes during interaction and elicited through physical examination techniques
Objective Data
To become proficient with physical assessment, the nurse should know what 3 things?
- Types and operation of equipment needed for the particular
examination - Preparation of the setting, oneself and the client for the
physical assessment - Performance of the four assessment techniques: Inspection,
Palpation, Percussion and Auscultation
To protect examiner in any part of the examination when the examiner may have contact with blood, bodily fluids, secretions, excretions, and contaminated items or when disease-causing agents could be transmitted to or from the client
Gloves and Gowns
Used to measure diastolic and systolic blood pressure.
Sphygmomanometer
Used to auscultate blood sounds when measuring blood pressure
Stethoscope
To measure body temperature
Thermometer
Who made the faces pain rating scale?
Wong-Baker
Used to measure skinfold thickness of subcutaneous tissue
Skinfold calipers
What are tools used for nutritional status examination
- Platform Scale
- Skinfold calipers
- Flexible tape measure
- Skin marking pen
What are tools used for skin, hair, and nail examination
- Examination light
- Penlight
- Mirror
- Metric ruler
- Magnifying glass
- Wood’s light
What are tools used for Eye examination
- Penlight
- Snellen Chart to test distant vision
- Newspaper to test near vision
For continued:
1. Opaque card
2. Ophthalmoscope
What are tools used for ear examination
- Tuning fork
- Otoscope
What are tools used for mouth, throat, nose, and sinus examination
- Penlight
- 4x4-inch small gauze pad
- Tongue depressor
- Otoscope
What are tools for thoracic and lung examination
- Stethoscope to auscultate breath sounds
- Metric rules
- Skin marking pen
What are tools used for heart and neck vessel examination
- Stethoscope
- Two Metric ruler
What are tools used in peripheral vascular examination
- Sphygmomanometer and stethoscope
- Flexible metric measuring tape
- Tuning fork
- Doppler ultrasound device and conductivity gel
What are tools used in abdominal examination
- Stethoscope
- Flexible metric measuring tape
- Skin marking pen
- Two small pillows
What are tools used in Musculoskeletal Examination
- Flexible metric measuring tape
- Goniometer
What are tools used in Neurologic Examination
- Cotton tipped applicator
- Newspaper
- Ophthalmoscope
- Flexible metric measuring tape
- Objects to feel
- Reflex hammer
Continued:
1. Cotton ball and paper clip
2. Substances to smell and taste
3. Snellen E chart
4. Penlight
5. Tongue depressor
6. Tuning fork
What are tools used for male genitalia and rectum examination
1, Gloves and water-soluble lubricant
2. Penlight
3. Specimen card for occult blood (pwet blood ;-;)
What are tools used for female genitalia and rectum examination
- Vaginal speculum and water soluble lubricant
- Bifid spatula, endocervical broom
- Large swabs for vaginal examination
continued:
1. Liquid pap medium
2. pH paper
3. Feminine napkins
What are the steps in preparing for the examination?
- Preparing the physical setting
- Preparing oneself
- Approaching and preparing the client
In preparing the physical setting ensure the room is
- Comfortable, warm room temperature and provide blanket if necessary
- Private area is free of interruptions. Close door/pull curtains if possible
- Quiet area free of distraction: Turn off the radio, television or other noisy equipment
- Adequate lighting: best to use sunlight
- Firm examination table or bed at a height that prevents stooping
- Bedside table/tray to hold equipment needed for examination
In preparing oneself what should you do?
- Assess your own feelings and anxieties before examining the client
- Your thoughts and feelings may be easily conveyed to the client (Cross-Transference)
- Achieve self-confidence in performing PE by practicing with a classmate, friend or
relative - Prepare Personal Protective Equipment depending on the examination to be done
(based on OSHA, CDC & DOH Guidelines) - Wash hands (refer to lecture on Infection Control)
- If pin or other sharp object is used to assess, discard the pin and use a new one for
your next client
In approaching and preparing the client what should you do?
Explain to the client that the physical assessment will follow and describe what
the examination will involve
* Respect client’s desires and requests related to the physical exam. Some
institutions need a consent form prior to any assessment
* PRIVACY CONCERNS
* Leave the room while the client changes into a gown and knock before re-
entering
* Allow the client to wear underwear until genitalia assessment is needed
* Lock doors, close curtains/ drapes
* Begin with less intrusive procedures
IF urine specimen is needed, explain and provide a container. Otherwise, ask
the client to urinate prior to the exam to promote easier and more
comfortable exam of the abdomen and genital area
* Continue explaining while the procedure is ease client’s anxiety
* It is helpful to integrate health teaching and promotion during examination
* Approach on the right-hand side (most procedures utilizes the right hand of
examiner)
* Prepare client for position changes and inquire if they would need assistance
Identify the pe position:
This position is good for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities. This position is also useful because it permits full expansion of the lungs and it allows the examiner to asses symmetry of upper body parts.
Sitting Position
Identify the pe position:
A small pillow may be placed under the head to promote comfort. If the client has trouble breathing, the head of the bed may need to be raised. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities
Supine
Identify the pe position:
The client lies down on the examination table or bed with knees bent, the legs separated, and the feet flat on the table of bed. This position may be more comfortable than the supine position for clients with pain in the back or abdomen. Areas that may be assessed with the client in this position include head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses. The abdomen should not be assessed because the abdominal muscles are contracted in this position
Dorsal recumbent position
Identify the pe position:
The client lies on the right or left side with the lower arm placed behind the body and the upper arm flexed at the should and elbow. The lower leg is slightly flexed at the knee while the upper leg in flexed at a sharper angle and pulled forward. This position is useful for assessing the rectal and vaginal areas. The client may need some assistance getting into this position. Clients with joint problems and elderly clients may have some difficulty assuming and maintaining this position
Sims’ position
Identify the pe position:
The client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia
Standing Position
Identify the pe position:
The client lies down on the abdomen with head to the side. The prone position is used primarily to assess the hip joint. The back can also be assessed with the client in this position. Clients with cardiac and respiratory problems cannot tolerate this position
Prone
Identify the pe position:
The client kneels on the examination table with the weight of the body supported by the chest knees. A 90-degrees angle should exist between the body and the hips. The arms are placed above the head, with the head turned to one side. This position is useful for examining the rectum.
Knee-chest
Identify the pe position:
The client lies on the back with hips at the edge of the examination table and the feet supported by stirrups. This position is used to examine the female genitalia, reproductive tracts, and the rectum. The client may require assistance getting into this position. It is an exposed position, and clients may feel embarrassed. In addition, elderly clients may not be able to assume this position for very long or at all.
Lithotomy Position
What are the 4 physical examination techniques?
1, Inspection
2. Palpation
3. Percussion
4. Auscultation
Involves using the senses of vision, smell and hearing to observe and detect any normal or abnormal findings. Is usually done first since latter techniques can alter the appearance of the body part inspected
Inspection
In inspection what 11 things should you take note of?
- Color
- Patterns
- Size
- locations
- consistency
- symmetry
- movement
- behavior
- odors
- sounds
- symmetry of paired body parts
Consists of using parts of the hand to touch and feel
Palpation
In palpation what are the descriptors of the following:
Texture
Rough/smooth
In palpation what are the descriptors of the following:
Moisture
Dry/wet
In palpation what are the descriptors of the following:
Consistency and degree of tenderness
Soft/hard/fluid filled
In palpation what are the descriptors of the following:
Size
small/medium/large
In palpation what are the descriptors of the following:
Temperature
Warm/cold
In palpation what are the descriptors of the following:
Mobility
Fixed/movable/still vibrating
In palpation what are the descriptors of the following:
Strength of pulses
Strong/weak/thready/bounding
In palpation what are the descriptors of the following:
Shape
well defined/irregular
In palpation for the following what is used:
Fine discriminations: pulses, texture, size, consistency, shape, crepitus
Fingerpads
In palpation for the following what is used:
Vibrations, thrills, fremitus
Ulnar or palmar surface
In palpation for the following what is used:
Temperature
Dorsal (back) surface
What are the 4 palpation types?
Light, moderate, deep, bi-manual(Using two hands)
True or False:
When palpating, use finger pads and not tips of fingers to palpate
True
Involves tapping body parts to produce sound waves
Percussion
For percussion what should be done to identify the following:
Detect inflamed structures
Eliciting pain
For percussion what should be done to identify the following:
Changes between borders of an organ
Determine location, size and shape
For percussion what should be done to identify the following:
If filled with are/fluid/solid structure
Determining density
For percussion what should be done to identify the following:
can detect superficial abnormal structures or _____
Detecting abnormal masses
For percussion what should be done to identify the following:
Through percussion hammer
Eliciting reflexes
What are the 3 types of percussions
Direct, Blunt, Indirect
Identify the type of percussion:
Tapping of a body part with 1 or 2 fingers
Direct
Identify the type of percussion:
Placing hand on the body surface and using fist of the other hand to strike the back of the hand flat
Blunt
Identify the type of percussion:
Most common type produces a sound/tone that varies with density of the structures
Indirect
Requires the use of stethoscope to listen for heart sounds, movement of blood through the cardiovascular, movement of bowel and movement of air through respiratory tract
Auscultation
What is the 3rd step of health assessment
Validating of Data
The process of confirming the subjective and objective data you have collected are reliable and accurate
Validation
What is the 4th step of nursing assessment?
Documenting and reporting data
What are the guidelines for documentation
- Keep confidential all documented information in the client record
- Document legibly and print neatly in nonerasable ink
- Use correct grammar and spelling. Use only abbreviations that are acceptable
and approved by the institution - Avoid wordiness that creates redundancy
- Use phrases instead of sentences to record data
- Record data findings, not how they are obtained
- Write entries objectively without making premature judgments or diagnoses
- Record the client’s understanding and perception
- Avoid recording the word “normal” for normal findings
- Record complete information and details for all client symptoms or
experiences - Include additional assessment content when applicable
- Support objective data with specific observations obtained during physical
examination
In signing nurses’ notes to discourage others from adding information the the nurses’ notes, what should you do?
Draw a line through any blank spaces and sign you name at the far right of the column
Anytime one health care provider is transferring client care responsibilities to another healthcare provider
Handoff
What is another word for handoff
Endorsement
Verbal communication of data
- Use standardized method of data communication (SBAR)
- Communicate with good eye contact and face-to-face
- Allow time for the receiver to ask questions
- Provide documentation of the data you are sharing
- Validate what the receiver has heard by questioning or asking to summarize
report - Telephone reports: record time, receiver, sender and information shared
What is SBAR
Situation, Background, Assessment, Recommendation
What part of SBAR:
States concisely why you need to communicate the client data that you have assessed (example: Mary Lorno, age `8, is experiencing a sudden onset of periumbilical pain
Situation
What part of SBAR:
Describes the events that led up to the current situation (Example: client first noticed periumbilical pain at 10:30. She denies any precipitating factors)
Background
What part of SBAR:
State the subjective and objective data you have collected
Assessment
What part of SBAR:
Suggest what you believe needs to be done for the client based on your assessment findings (example: suggest that the primary care provider come to further assess the client and intervene)
Recommendations
What is the first step of the nursing process?
Nursing Assessment
